What to do for a patient who has developed jaundice?

Initial Workup for a Jaundiced Patient

Order an abdominal ultrasound immediately as the first-line imaging study, along with comprehensive laboratory testing including total and fractionated bilirubin, complete blood count, liver enzymes (AST, ALT, alkaline phosphatase, GGT), and coagulation studies (INR/PT). 1

Laboratory Testing Priority

• Measure total and direct (conjugated) bilirubin to differentiate between obstructive (conjugated hyperbilirubinemia) and non-obstructive causes (unconjugated hyperbilirubinemia) 1
• Check AST, ALT, alkaline phosphatase, and GGT to determine if the pattern is hepatocellular (AST/ALT predominant) versus cholestatic (alkaline phosphatase/GGT predominant) 1
• Obtain INR/PT and albumin to assess synthetic liver function 1
• Order blood, urine, and ascitic fluid cultures (if ascites present) to exclude bacterial infection, regardless of fever presence, particularly if alcoholic hepatitis is suspected 2

First-Line Imaging: Abdominal Ultrasound

Ultrasound is the recommended initial imaging modality because it is non-invasive, readily available, and highly effective at determining whether biliary obstruction is present 2, 1

What Ultrasound Reveals:

• Detects biliary ductal dilation with sensitivity 32-100% and specificity 71-97% for obstructive jaundice 2
• Identifies cirrhosis with sensitivity 65-95% and positive predictive value of 98% (look for nodular liver surface, especially on the undersurface which is 86% sensitive) 2
• May visualize the cause of obstruction including gallstones, masses, or pancreatic pathology, though distal common bile duct visualization can be limited by bowel gas 2

Critical Pitfall:

A normal-caliber common bile duct on ultrasound does NOT exclude acute obstruction, as bile ducts may not dilate immediately with acute blockage 2

Next Steps Based on Ultrasound Findings

If Dilated Bile Ducts Are Present (Obstructive Pattern):

Proceed to MRCP (magnetic resonance cholangiopancreatography) or contrast-enhanced CT to determine the level and cause of obstruction 2, 1

• MRCP is preferred when you need detailed biliary anatomy, suspect hilar obstruction, or the patient has contraindications to ERCP 2
• MRCP is more sensitive than CT for detecting liver metastases from pancreaticobiliary malignancies (use diffusion sequences and gadoxetate disodium) 2
• Contrast-enhanced CT (64-slice or higher) has 74-96% sensitivity and 90-94% specificity for biliary obstruction, and is excellent for staging malignancies with 80.5-97% accuracy 2
• Use caution with iodinated contrast in patients with suspected alcoholic hepatitis or renal dysfunction, as it increases acute kidney injury risk 2

If No Biliary Dilation (Non-Obstructive Pattern):

Do NOT stop at a negative ultrasound - proceed with additional imaging (MRCP or contrast-enhanced CT/MRI) to exclude hepatic masses, biliary strictures, or pancreatic pathology that may not cause ductal dilation 2

• Consider MRI/MRCP if primary sclerosing cholangitis or primary biliary cirrhosis is suspected 2
• Liver biopsy may be needed if imaging remains unrevealing and laboratory workup suggests intrinsic liver disease 2

When to Proceed Directly to ERCP

Reserve ERCP for therapeutic intervention, not initial diagnosis, as it carries 4-5% morbidity and 0.4% mortality risk 2

ERCP is appropriate when:

• High suspicion for choledocholithiasis with dilated common bile duct on imaging and need for stone extraction (80-95% success rate) 2
• Biliary decompression is urgently needed for septic cholangitis or severe obstruction 2
• Tissue diagnosis is required via brush cytology or biopsy during the procedure 2

Special Considerations for Alcoholic Hepatitis

If clinical picture suggests alcoholic hepatitis (heavy alcohol use >40g/day, bilirubin >3.0 mg/dL, AST >50 but <400 IU/L, AST/ALT ratio >1.5):

• Admit to hospital if severe disease (Maddrey Discriminant Function >32 or MELD >20) or inadequate social support 2
• Avoid nephrotoxic drugs including diuretics as acute kidney injury is an early manifestation of multi-organ failure 2
• Provide aggressive nutritional support (1-1.5g protein and 30-40 kcal/kg body weight) via enteral feeding if needed 2

Critical Pitfalls to Avoid

• Never assume jaundice with normal bile ducts is "just hepatitis" - tumors, strictures, and pancreatic pathology can present without ductal dilation 2
• Do not delay imaging in favor of "watchful waiting" - early detection of malignancy dramatically affects resectability and survival 2
• Avoid performing ERCP as a diagnostic test when non-invasive MRCP can provide equivalent information without procedural risks 2
• Screen for infection before administering immunosuppressive therapy (like corticosteroids for alcoholic hepatitis) 2